Inquest into the Death of K.P.

Contributing factors

• failure to review safety assessment after hospital discharge
• failure to conduct risk assessment
• inadequate engagement with mother regarding living circumstances and support
• gaps in child protection home visitation - no caseworker visits for six weeks prior to death
• maternal disengagement with health and support services
• missing appointments by mother with healthcare and casework appointments
• lack of formal coordination and documentation of interagency information sharing through SAFE START
• unclear allocation of roles and responsibilities between health services for SAFE START administration
• suboptimal response to missed medical appointment on 17 January 2022 - lacking urgency
• inadequate use of maternal grandparents as safety resources without explicit discussion of mother's drug use
• staff leave during critical holiday period with inadequate case handover
• maternal mental health issues not adequately explored or supported

Coroner's recommendations

1. To the Chief Executive Officer, Albury Wodonga Health and Murrumbidgee Local Health District: that AWH and MLHD consult with a view to formalising the administration and governance of the SAFE START Program for the Murrumbidgee Local Health District and the Albury Wodonga health catchment, which is networked with Victoria. This consultation should consider formalising: (a) a clear and documented allocation of roles and shared distribution of responsibility for the administration of the SAFE START program between each health service; (b) which agencies will be responsible for the administration of the program; (c) expectations for participation by the agencies in case management meetings; (d) minute taking and distribution of minutes; and (e) a process to identify and track agreed action.